Please use the information on this page to help ensure your dental claims are processed quickly and correctly. Note: Please do not submit attachments (e.g., X-rays, periodontal chartings) with your pretreatment estimate or initial claims submission. If additional information is needed, we will send you a request.
On January 1, 2021, we will require diagnosis codes on certain dental claims to support expanded dental care benefits for patients with such conditions as heart disease, diabetes or pregnancy. Diagnostic codes will identify why a procedure was performed and the associated disease, illness symptom or disorder.
We encourage you to begin including diagnosis codes when submitting dental claims to us as soon as possible. To submit your dental claims using the online claims submission tool on the Availity Portal: Go to - Claims & Payment>Dental Claim. You can submit up to four diagnosis codes in the Record of Services Provided section.
The Avality Portal also includes training on how to submit a dental claim: Go to – Help & Training>Find Help>Claim Submission>Dental Claims>Submitting Dental Claims.
- The 2020 CDT Dental Procedure Codes manual includes diagnosis codes and the 2020 CDT Coding Companion book also has information about frequently used CDT procedure codes followed by possible diagnoses and their ICD-10 codes. Examples of possible diagnosis codes include:
- Coronary Atherosclerosis: I25 (chronic ischemic heart disease)
- Diabetes: E08, E09, E10 and E11
- Hypertensive heart disease: I11 and I13
- Pregnancy: Z33
View a table of commonly reported dental procedures with examples of possible diagnoses and related ICD codes on The American Dental Association (ADA) Center for Professional Success website.
The following are not eligible for reimbursement and should not be billed to us or to the member:
- Denture insertion.
- Periodontal charting.
- Completion of claim forms.
- Reports to referring providers.
- Original soldering of bridge units.
- Dressings by the treating dentist.
- Duplication or submission of X-rays.
- Indirect pulp caps, bases and liners.
- Separate lab charges in addition to crown.
- More than four pins per restoration (tooth).
- Gold in addition to the cast gold restorations.
- Finance charges on the amount paid by Regence.
- Reline in addition to a separate charge for a rebase.
- Bitewing X-rays in addition to a complete X-ray series.
- Surgical procedure for isolation of a tooth with a rubber dam.
- Local or regional anesthetic in addition to operative procedures.
- Occlusal adjustment charges in addition to occlusal restorations.
- Root canal culture (considered inclusive to the root canal procedure).
- Alveoloplasty (alveolectomy) in conjunction with fewer than three extractions.
- Individual periapical X-rays performed on the same day as a complete X-ray series.
- Sedative or temporary fillings performed on the same day as permanent restorations.
- Billings (original or corrected) that are more than twelve months old after the date of service.
- Root recovery in addition to a charge for the extraction of the same tooth by the same dentist.
- Any services normally considered part of overhead (e.g. sterilization, infection control, asepses).
- Charges for full or partial denture relines or adjustments done less than six months after the initial placement.
- Acid etch or a light-cured restoration in addition to charges for restorative procedures on the same tooth.
- Root planing and scaling if those procedures follow curettage, gingivectomy or osseous surgery done in the same area within one year.
- Any combination of the following Current Dental Terminology (CDT) codes if performed on the same day: CDT D1110, D1120, D4210, D4211, D4260, D4261, D4341, D4910.
Charges for advanced technology including but not limited to laser, robotics, computer assistance, etc, in addition to the charge for the procedure. For further information please refer to Dental Policy #70 – Non-Reimbursable Dental Services under Miscellaneous section.
Submit a dental benefit predetermination (pretreatment estimate) electronically for a courtesy review. Our response will be sent to you via letter. Note: Predeterminations cannot be viewed on the Availity Portal.
Benefits will be predetermined under the assumption that Regence is the primary insurer. If the patient is insured under more than one policy, actual benefits payable may be adjusted due to coordination of benefits (COB) or maintenance (non-duplication) of benefits (MOB).
Predeterminations are provided as a courtesy and are not a guarantee of payment. All services are subject to the benefits, eligibility and maximum allowable amounts in effect on the actual date of service. Estimated payment may be reduced due to prior payments for treatment. Actual benefits payable will depend upon the following:
- Benefits available
- Member contract limitations
- Provider participating status
- Patient and provider eligibility
Benefit maximums in effect when the services are completed
Orthodontia is a separate benefit from other dental services. Check the member's benefits to determine whether it is a covered service. Orthodontia for periodontal reasons is covered only if the patient has orthodontic benefits. Please access the Availity Provider Portal prior to treatment to determine if your patient has orthodontic benefits.
You can bill the total orthodontia treatment cost up-front without the breakdown of payments, except when treatment was received prior to eligibility or probation:
Notes related to the above exception:
Submit claims electronically using valid orthodontic codes along with the following information in the Claims Notes or Remarks section:
- Banding date
- Total treatment charge
- Monthly payment amount
- Estimated length of treatment
- Initial banding fee or down payment
- Orthodontic treatment that started before the member's effective with Asuris will be reimbursed in proportion to the time remaining in treatment.
Example: If a member's effective date with Asuris is in the sixth month of a 24-month course of treatment, payment will be prorated to the 18 months in which they become eligible. This payment, when combined with any payment made by a previous insurance carrier, cannot exceed the total billed amount.
Note: Orthodontia benefits for some groups are structured to pay for periodic treatment visits, as indicated in the member's benefits. If you are not able to submit electronic claims for periodic treatments and the payment received for your initial claim is not equal to the amount of the member's available orthodontia benefit, please submit monthly or quarterly visit claims until benefits are exhausted or the patient completes treatment via fax to 1 (888) 606-6582. The last claim for treatment must indicate the date that the patient was de-banded.
The following criteria are used to determine if a service is necessary:
- It is consistent with widely accepted standards of practice.
- It is not primarily for the convenience of the member, the dental provider or any other person.
- It could not have been omitted without adversely affecting the member's condition or quality of care.
- It is the least costly, appropriate treatment and location that can be used safely to treat the member's condition.
It is the appropriate type, level, amount and frequency of care necessary to treat a dental condition or injury that is harmful to the health of a member.
A dental accidental injury is defined as involving damage to the natural, sound and healthy tooth or tooth structure.
Dental offices performing procedures not on or contiguous to a tooth must report the service on a medical claim form, with Current Procedure Terminology (CPT®) codes. These codes must be reported with the appropriate ICD-10 diagnosis codes.
ICD-10 coding resources
These resources may be helpful when submitting medical claims which require ICD-10 coding:
The following are examples of common services that should be billed as a medical claim. This list is not all-inclusive and should be used as a reference only.
The following illustrates some common examples of services that should be billed as a medical benefit. This list is not all-inclusive and should be used as a reference only.
HCPCS E0486 Oral Device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, custom fabricated, includes fitting and adjustment
- CPT 21085 Impression and custom preparation; oral surgical splint (Should not be used without surgery intervention)
CPT 21089 Impression and custom preparation; unlisted maxillofacial prosthetic procedure (Used to report mandibular repositioning devices where surgery is not part of the treatment plan for splint placement.)
- CPT 21248 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial
CPT 21249 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete
- CPT 40490 Biopsy of lip
CPT 40808 Biopsy, vestibule of mouth
- CPT 41899 Unlisted procedure, dentoalveolar structures can be used for extractions, crowns, build ups, root canals, dentures, or other procedures not separately identified with a CPT or HCPCS code
Note: Include the corresponding CDT code in the 2400 Loop, in the SV1 segment (professional service) and the SV101-7 (description) of the electronic medical claim
If you have any questions, please contact your dental provider experience representative.